In a multi-institutional prospective study of more than 300 patients with advanced cancer, black patients tended to receive life-prolonging measures at the end of life -- even when they had do-not-resuscitate (DNR) orders in place or stated a preference for comfort care only, according to Jennifer W. Mack, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and colleagues.

White patients appeared to get more benefit from end-of-life discussions, receiving care largely in accord with their stated preferences, Mack and co-authors wrote in the Sept. 27 issue of the Archives of Internal Medicine.

This occurreddespite the finding that just over a third of patients in both groups talked about end-of-life care with their doctors.

"In the past, people have often thought of disparities in end-of-life care as mostly being a function of preferences, that black patients are more likely to prefer and receive life prolonging end-of-life care," Mack told MedPage Today.

But based on the study, that's probably not the case, she explained. "There are probably other likely nonpatient factors at work here," she said in an interview.

Just what those nonpatient factors may be is not clear. Possibilities may include less continuity of care for black patients, leading to less readily available documentation of end-of-life preferences, or racial biases among clinicians about what care patients want, she suggested.

The bottom line, though, is that too few patients -- black or white -- actually have discussions about end-of-life care, she noted.

In the current study, just 35.3% of black patients and 38.4% of white patients with advanced cancer had end-of-life care discussions with their physicians.

The study included a cohort of 71 black patients and 261 white patients with advanced cancer participating in the larger Coping with Cancer Study at a number of institutions around the U.S.

Despite the similar likelihood of end-of-life discussions between the two groups (P=0.65), black patients were:

Less aware of the terminal nature of their illness (31.8% versus 47.3%, P=0.02)

Less likely to prefer symptom-directed care over life-prolonging care at the end of life (78.5% versus 63.2%, P=0.01)

Less likely to have do-not-resuscitate orders in place (50.4% versus 30.9%, P=0.005)

More likely to receive life-prolonging care in the last week of life (19.7% versus 6.9%, P=0.001)

Black patients also did appear to benefit as much from end-of-life care discussions as their white counterparts.

Those who had such conversations preferred symptom-directed care 3.85 times more often than those who didn't have the discussions with clinicians, and blacks were 4.25 times more likely to have a DNR order in place.

While a preference for comfort care increased the likelihood of hospice care in the last week of life among blacks (P=0.02), those with a DNR order were no less likely to get life-prolonging care at the end of life (P=0.58), nor were they more likely to get care consistent with their preferences (P=0.82).

On the other hand, for white patients end-of-life discussions consistently correlated with outcomes, leading to lower likelihood of life-prolonging care (adjusted odds ratio 0.11, P=0.04), greater chances of hospice care (adjusted OR 1.99, P=0.04), and receipt of care in accord with stated preferences (adjusted OR 2.59, P=0.02).

"Although end-of-life discussions and communication goals assist white patients in receiving less burdensome life-prolonging care at the end of life, black patients tend to receive more aggressive care regardless of their preferences," Mack and co-authors wrote.

They cautioned that the study included relatively few black patients and relied on the patients' reports of end-of-life care discussions.

Other limitations included variations in attributes that may define a patient's experience of quality end-of-life care, which require further study.

"Although the reasons for our findings are not fully understood, white patients appear to have undefined advantages" when it comes to end-of-life care that reflects their values. "Care of black patients ... must be brought to the same standard," Mack and co-authors concluded.

The study was supported by grants from the National Institute of Mental Health and the National Cancer Institute, by a Fetzer Religion at the End-of-Life Grant, and by the Center for Psycho-oncology and Palliative Care Research at Dana-Farber Cancer Institute.

Mack reported being supported by an American Cancer Society Mentored Research Scholar Grant.

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